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RESEA R C H Open Access
Development of a practical guide for the early
recognition for malignant melanoma of the foot
and nail unit
Ivan R Bristow
1*
, David AR de Berker
2
Abstract
Background: Malignant melanoma is a rare but potentially lethal form of cancer which may arise on the foot.
Evidence suggests that due to misdiagnosis and later recognition, foot melanoma has a poorer prognosis than
cutaneous melanoma elsewhere.
Methods: A panel of experts representing podiatry and dermatologists with a special interest in skin oncology was
assembled to review the literature and clinical evidence to develop a clinical guide for the early recognition of
plantar and nail unit melanoma.
Results: A systematic review of the literature revealed little high quality data to inform the guide. However a
significant number of case reports and series were available for analysis. From these, the salient features were
collated and summarised into the guide. Based on these features a new acronym “CUBED” for foot melanoma was
drafted and incorporated in the guide.
Conclusions: The use of this guide may help clinic ians in their assessment of suspicious lesions on the foot
(including the nail unit). Earlier detection of suspicious pedal lesions may facilitate earlier referral for exper t
assessment and definitive diagnosis. The guide is currently being field tested amongst practitioners.
Introduction
The incidence of malignant melanoma (MM) continues
to rise in the UK and Europe [1]. Despite being an
uncommon form of skin cancer it is responsibl e for the
majority of skin cancer deaths [2]. Health education
campaigns have increased public awareness of the pro-
blem and there is ev idence to show that sectors of the
population are presenting earlier with their suspicious
skin lesions [3-5]. Despite these improvements, mortality

and morbidity still remains high, particularly within sub-
sets of the population such as older adults [6,7], males
[8-10], the less affluent [11] and less well educated
[12,13].
Around 3-15% of all cutaneous MM arise on the foot
[14,15]. However, MM arising on the foot holds a
poorer prognosis than melanoma elsewhere [16,17]. The
reasons for this are not certain, but there are several
possible explanations. The basic prognost ic indicator for
melanoma at all sites is the thickness of the tumour as
measured under the microscope in millimetres. This is
known as the Breslow thickness. The greater the thick-
ness of the tumour, the more likel y that the patient will
die in the following five years. Thick lesions on the
hands and feet have been shown to have a worse prog-
nosis than tumours of a similar thickness elsewhere
[18]. Some investigators have attributed this to pedal
lesions being more aggressive in nature [19], though
others have disputed this as a statistical anomaly due to
the small numbers involved [20]. Other authors have
suggested that the Breslow thickness grading in plantar
and nail melanoma is often more difficult to determine
or inconclusive [21].
Delay in diagnosis is a further factor, where the length
of history of the melanoma has a correlation with Bre-
slow thickness and hence deterioration of prognosis.
Foot lesions are often detected by health care practi-
tioners later than lesions elsewhere. A tumour on the
face is more likely to result in prompt action by the
* Correspondence:

1
School of Health Sciences, University of Southampton, Highfield,
Southampton, SO17 1BJ, UK
Full list of author information is available at the end of the article
Bristow and de Berker Journal of Foot and Ankle Research 2010, 3:22
/>JOURNAL OF FOOT
AND ANKLE RESEARCH
© 2010 Bristow and de Berker; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License ( s/by/2.0), which permits unrestricted use, distribution, and
reproduction in any me dium, pr ovided the original work is properly cited.
patient and practitioner than one on the foot. Further-
more, lesions between the toes, beneath the nail or on
the sole are further concealed. As a result, delayed pre-
sentation results in thicker, more advanced tumours
[22-24]. Secondly, foot melanoma, possibly because of
its rarity, is frequently misdiagnosed as a more common
foot disorder such as tinea pedis [25-29], onychomycosis
[30], warts [31-36], haematoma [25,37-39], paronychia
[40], ingrowing toe nail [41-43], bacterial infection [44],
ischaemia or necrosis [14,40], blisters, ganglions, callus
[42], benign tumours [45,46] and ulceration [47-54].
Misdiagnosis rate for foot lesions have been reported to
be between 25%-66% [14,25,40] compared with much
lower rates of around 12-16% for melanoma in other
anatomical locations [27,55,56]. This is probably a
reflection of the fact that patients do not initially sus-
pect the diagnosis of skin cancer at these sites and
therefore consult healthcare professionals other than
dermatologists with lesions who may not be so aware of
the possibility of a malignant lesion.

The priority of skin cancer has been highlighted by
the Government in its strategy to reform Cancer Ser-
vices in the UK [57]. Through the “SUNSMART” cam-
paign , the government aims
to increase public awareness of the disease and stress
the importance of seeking professional opinion. On the
professional side, guidelines issued from the National
Institute for Clinical Excellence (NICE) stress the impor-
tance of health care professionals being aware of the
modified 7-point checklist [58] for a ssessment of pig-
mented skin lesions and where any patient presenting
with a skin lesions should be referred to a specialist skin
car e team [59]. Some guidelines have been published in
the UK and Australasia, specifically for medical practi-
tioners for melanoma [60-62] but none are known to
exist specifically for lesions arising on the foot. A review
of cases in one district [25], demonstrated a significant
number of melanoma cases were seen by foot specialists
prior to diagnosis.
The need for greater awareness to permit earlier
recognition of foot melanoma amongst health care prac-
titioners has been expressed [22]. In turn this could lead
to faster recognition, referral and diagnosis. Authors
have commented that the traditional melanoma screen-
ing algorithms, the ABCDE system & 7-point checklist
maybelesseffectivewhenappliedtothefoot
[25,40,63]. The plantar surface with its thickened epider-
mis is subject to trauma and hyp erkeratotic changes
which are not found elsewhere and may disguise critical
signs.

In conjunction with the Society of Chiropodist s and
Podiatrists (Faculty of Podiatric Medicine and General
Practice), a panel was convened to draft guidance for its
members to raise awareness of the condition. The guide
development group consisted of a team consisting of a
podiatrist and four dermatologists each with a special
interest in skin cancer.
Methods
Initially the panel compiled a list of clinical questions
relevant to the topic of foot and nail melanoma to help
inform a search strategy. A literature search was under-
taken using the National Library of Medicine (NLM)
PubMed database to identify literature on foot and nail
melanoma. A range of search terms was devised (see
below):
1: foot OR feet OR “lower extremity” OR acral OR
plantarORnailORlegORankleORsub-ungual
(233864)
2: melanoma (74768)
3: Diagn* OR recogn*OR screen* (2518063)
Limits: English Language & Human
Total of combination: 843
From the initial sweep (n = 843), papers whose pri-
mary focus fell outside of the topic (i.e. did not discuss
recognition, detection, diagnosis and features) were dis-
carded, typically these included pap ers solely discussing
prognosis and survival, surgery and management. Papers
which also made brief mention of the foot with no sub-
set analyses w ere excluded. The r emaining papers were
reviewed, by both authors, using guidance as outlined by

the National Institute for Clinical Excellence [64](Table
1). Papers were classified accord ing to their level of evi-
dence and reviewed for content. In addition, a separate
search was undertaken to establish if previous, relevant
guidelines had been published elsewhere.
Results
The review of the literature identified a lack of high
level evidence to inform the development of a guide.
Table 1 Levels of evidence (adapted from [64])
Level of
Evidence
Type of evidence
1** High quality meta-analyses, or systematic reviews of
randomised controlled trials (RCTs).
1* Well conducted meta-analyses, systematic reviews of
RCTs.
1- Meta-analyses, systematic reviews of RCTs or RCTs with
a high risk of bias.
2** High quality systematic reviews of cohort or case-
control studies. High quality cohort or case-control
studies with a low risk of confounding bias or chance.
2* Well conducted case-control or cohort studies with a
low risk of confounding bias or chance.
2 Case-control or cohort studies with a high risk of
confounding bias or chance.
3 Non-analytic studies (case reports, case series).
4 Expert opinion, formal consensus.
Bristow and de Berker Journal of Foot and Ankle Research 2010, 3:22
/>Page 2 of 4
Based on the NICE grading system, a small number of

case-co ntrol studies were identified examining aetiology,
incidence and clinical features (level 2). Most of the
published literature pertaining to foot melanoma was
ranked at level 3, being predominantly case reports (n =
44), literature reviews/discussions (n = 21) and case ser-
ies (n = 14) of foot melanoma. On this basis, it was
accepted that the paper would be drafted on the
strength of the available evidence with informed consen-
sus methods amongst the group to develop guidance.
All case reports and case series were examined by the
authors. The hierarchy of evidence places such literature
at a low level, just above that of medical opinion. How-
ever, case studies have the capacity to report rare dis-
eases or the manifestations of disease which can be a
useful learning tool in medical education [65]. The
authors reviewed these papers looking for common
themes, key messages and learning points. The focus o f
such papers was often around misdiagnosis, delay and
deterioration of the lesion. Based on this data, a new
acronym was proposed specific for foot melanoma. An
existing ABCDE acronym was included for nail mela-
noma [66].
Subsequent to drafting the paper was reviewed by the
panel. External reviewers were identified. These included
practi sing podiatr ists and chir opodists, a general practi-
tioner, a diabetologist and other specialists involved in
foot care. To facilitate a simple and rapid feedback
mechanism, participants were electronically e-mailed a
copy of the draft guidelines and then asked to respond
by an online feedback website. Respondents were a sked

to comment on the draft including content, readability
and clarity of the draft document. Following the consul-
tation, amendments were made and the guidelines have
been reviewed and have been submitted for publication.
Conclusions
The development and use of a guide may help clinicians
in their assessment of suspicious lesions on the foot
(including the nail unit). Earlier detection of suspicious
pedal lesions may facilitate earlier referral for expert
asse ssment and definitive diagnosis. The guide has been
tested amongst practitioners and has been submit ted for
publication.
Acknowledgements
The melanoma working group consisted of:
Ivan Bristow, Lecturer, School of Health Sciences, University of Southampton,
UK
David de Berker, Consultant Dermatologist, Bristol Royal Infirmary, Bristol, UK
Katharine Acland, Consultant Dermatologist, St John’s Institute of
Dermatology, St Thomas’ Hospital London, UK
Richard Turner, Consultant Dermatologist, Churchill Hospital, Oxford Radcliffe
Hospitals, Oxford, UK
Jonathan Bowling, Dermatologist, Churchill Hospital, Oxford Radcliffe
Hospitals, Oxford, UK
The authors would like to thank colleagues who reviewed the drafts and for
their detailed feedback including Laurie King and Alistair McInnes.
Author details
1
School of Health Sciences, University of Southampton, Highfield,
Southampton, SO17 1BJ, UK.
2

Bristol Dermatology Centre, Bristol Royal
Infirmary, Bristol, BS2 8HW, UK.
Authors’ contributions
IB was responsible for the original drafting of this paper. Subsequent
revisions and amendments were made jointly by DB and IB. Both authors
have read and approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 7 June 2010 Accepted: 28 September 2010
Published: 28 September 2010
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doi:10.1186/1757-1146-3-22
Cite this article as: Bristow and de Berker: Development of a practical
guide for the early recognition for malignant melanoma of the foot
and nail unit. Journal of Foot and Ankle Research 2010 3:22.
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